# A patient with cirrhosis and grade 2 hepatic encephalopathy has been started on lactulose. Which nursing actions reflect appropriate management of this patient? Select all that apply.

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> language: en  
> subject: Basic Care and Comfort  
> category: BCC

## Question

A patient with cirrhosis and grade 2 hepatic encephalopathy has been started on lactulose. Which nursing actions reflect appropriate management of this patient? Select all that apply.

1

Reorient frequently, place a clock and calendar in view, and limit overnight stimulation to support neurocognitive recovery.

2

Assess for asterixis (flapping tremor) and changes in level of consciousness at least every 4 hours to detect worsening encephalopathy.

3

Monitor serum ammonia trends and electrolytes — particularly potassium — given that lactulose-induced losses can precipitate hypokalemia.

4

Restrict dietary protein intake to minimal levels long-term to reduce ammonia production and prevent recurrent encephalopathy.

5

Titrate lactulose to achieve 2 to 3 soft stools per day, not loose explosive diarrhea, to balance ammonia clearance against fluid and electrolyte loss.

## Explanation

Hepatic encephalopathy management with lactulose targets 2 to 3 soft stools daily — too much causes hypokalemia and dehydration. Frequent neurologic assessment, ammonia and K+ monitoring, and reorientation are core nursing care. Choice 4 is wrong: current AASLD/EASL guidelines recommend a normal-protein diet (1.2 to 1.5 g/kg/day) — severe protein restriction worsens muscle wasting and outcomes; only transient short-term restriction is occasionally used.

## In-depth explanation

Lactulose works by acidifying the gut and trapping NH4+ for excretion; over-titration causes the very K+ losses that worsen encephalopathy. The "no protein restriction" rule is one of the highest-yield NCLEX traps — older textbooks teach the opposite of current evidence.

## Clinical scenario

**Cirrhotic patient** admitted with **grade 2 hepatic encephalopathy** (drowsy, asterixis present, mild disorientation). Provider has ordered **lactulose** titrated to therapeutic effect along with supportive care.

## Key concepts

- **Hepatic encephalopathy** — Reversible neuropsychiatric syndrome of cirrhosis driven by gut-derived ammonia bypassing the failing liver.
- **Asterixis** — Flapping tremor of dorsiflexed hands; classic clinical marker of encephalopathy grade 2.
- **Lactulose titration** — Adjust dose to 2 to 3 soft stools per day; over-titration causes hypokalemia and worsens encephalopathy.

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